Eligibility Form Discover if our support services are right for you or your loved ones. All FormsCareersFeedbackEligibilityReferralCareersFeedbackEligibilityReferralSay Hello! Call Us 1300 707 238 Email Us info@mindsetintervention.com Address We service the Greater Brisbane Area and the Gold CoastRegistered NDIS Service Provider Eligibility FormPlease enable JavaScript in your browser to complete this form.Please enable JavaScript in your browser to complete this form.Please complete this form to determine your eligibility for receiving services from Mindset Intervention. Your responses will remain confidential and will be used solely for assessing your eligibility.Personal InformationFull Name *Date of Birth *Gender *MaleFemaleOtherEmail Address *Phone Number *Address *Address Line 1Address Line 2CityState / Province / RegionPostal CodeAfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBolivia (Plurinational State of)Bonaire, Saint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos (Keeling) IslandsColombiaComorosCongoCongo (Democratic Republic of the)Cook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Kingdom of)EthiopiaFalkland Islands (Malvinas)Faroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHondurasHong KongHungaryIcelandIndiaIndonesiaIran (Islamic Republic of)IraqIreland (Republic of)Isle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea (Democratic People's Republic of)Korea (Republic of)KosovoKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesia (Federated States of)Moldova (Republic of)MonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth Macedonia (Republic of)Northern Mariana IslandsNorwayOmanPakistanPalauPalestine (State of)PanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint Martin (French part)Saint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint Maarten (Dutch part)SlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyrian Arab RepublicTaiwan, Republic of ChinaTajikistanTanzania (United Republic of)ThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUgandaUkraineUnited Arab EmiratesUnited Kingdom of Great Britain and Northern IrelandUnited States Minor Outlying IslandsUnited States of AmericaUruguayUzbekistanVanuatuVatican City StateVenezuela (Bolivarian Republic of)VietnamVirgin Islands (British)Virgin Islands (U.S.)Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland IslandsCountryHow did you hear about us? (Optional)Select OptionGoogleSocial Media (Facebook, Instagram, etc.)Word Of Mouth/ReferralOtherEligibility Questionaire1. Are you impacted by any disability? *YesNoPlease indicate whether you have a disability that impacts your daily life and requires support.If yes, please provide a brief description of your disability *2. NDIS Participant Status: *I am already an NDIS participant.I have applied for the NDIS.I am not an NDIS participant and have not applied.Are you currently an NDIS participant or have you applied for the NDIS?3. NDIS Number (if applicable):Please provide your NDIS number if you are already an NDIS participant.4. Support CategoryAccommodation/Tenancy (0101)Assist Life Stage Transition (0106)Assist Travel/Transport (0108)Assist Access/Maintain Employee (0102)Assist Personal Activities (0107)Daily Tasks/Shared Living (0115)Life Skills Development (0117)Community Participation (0125)InterventionsOtherPlease indicate the main category of support you are seeking.5. Do you have an NDIS funding plan in place? *YesNoUnsureIf yes, please provide the details of your funding plan.6. What are your goals and specific support needs? *Briefly describe your main goals and the specific support needs you are looking for.7. Please provide relevant medical or health information that may impact the services you require. *8. Additional Information *Is there any additional information you would like to share about your situation or needs?9. Permission to Contact NDIS *YesNoDo you grant us permission to contact the NDIS on your behalf to verify your eligibility and funding status?10. Are you of Aboriginal and/or Torres Strait Islander origin? *YesNo11. Preferred Contact Method *PhoneEmail12. Consent to Data Collection *I consentBy submitting this form, you consent to the collection and use of your personal information for the purpose of assessing your eligibility and providing relevant services.Attachments Drag & Drop Files, Choose Files to Upload You can upload up to 5 files.Upload any relevant documents using the field above.13. Signature *Please write your name to confirm your submission.Thank you for completing the eligibility form.Our team will review your information and contact you shortly to discuss your eligibility and next steps.For any immediate questions, please contact our customer support at info@mindsetintervention.comSubmit
